UK Marine Accident Investigation Branch (MAIB) has published an investigation report on the grounding of roll-on/roll-off (roro) passenger ferry Alfred, that took place in July 2022 in Scotland.
The incident
At 1400 on 5 July 2022, the UK registered roro passenger ferry Alfred grounded on the east coast of Swona Island, Pentland Firth, Scotland while on passage from Gills Bay, mainland Scotland, to St Margaret’s Hope, South Ronaldsay, Scotland. The impact caused injuries to 41 passengers and crew, and damage to Alfred’s port bulbous bow and almost all the vehicles being transported on board. The vessel subsequently refloated on the rising tide and continued to St Margaret’s Hope under its own power later that afternoon; there was no pollution.
The investigation found that the roro ferry grounded because the master experienced a loss of awareness while helming the vessel close inshore, almost certainly as a result of falling asleep for approximately 70 seconds. During this period the master allowed Alfred’s heading to swing towards the coast unchecked. When the master became aware of the vessel’s predicament he was unable to prevent the ferry striking the rocks at 13 knots.
The investigation also identified that Alfred’s passage plan was inadequate and that its Electronic Chart Display Information System, which was the ferry’s primary means of navigation, was not being used effectively to support safe navigation and warn of danger. Despite the passage plan being in place since the vessel entered service in 2019, neither the Pentland Ferries’ annual audits nor the Maritime and Coastguard Agency’s surveys had detected this safety issue.
Alfred grounded in waters controlled by Orkney Islands Council Harbour Authority. However, the harbour’s vessel traffic service was not monitoring the movement of the ferry and did not raise the alarm when it entered the guard zone around Swona Island. Once aground, Alfred’s emergency response did not follow the safety video shown to passengers before departure from port. The investigation established that this was because the vessel’s procedures and weekly drills had not adequately prepared the crew for the emergency. The investigation also found that the Pentland Ferries emergency response team ashore did not prompt the master to create a nominal list of those on board.
Analysis
- Safety issues directly contributing to the accident that have been addressed or resulted in recommendations
Alfred grounded on Swona Island because the master experienced a temporary loss of awareness while helming the ship very close to shore and allowed the vessel’s heading to swing towards the coast unchecked. When the master became aware of the vessel’s predicament, he was unable to prevent the vessel from striking the rocks at 13kts.
It is almost certain that Alfred’s master went to sleep for approximately 70 seconds immediately before the vessel grounded. This short sleep went unnoticed, and the master was neither awoken nor alerted because there was no bridge lookout and the BNWAS was switched off.
The direction provided in the Pentland Ferries SMS on the construction of Alfred’s passage plan between Gills Bay and St Margaret’s Hope was inadequate and did not prevent the master from navigating the vessel by eye, without the limits of safe navigable water being defined. As a result, ECDIS, which was Alfred’s primary means of navigation, was not being used to support safe navigation and warn of danger.
The master’s significant experience on the route and the highly repetitive nature of Alfred’s schedule between Gills Bay and St Margaret’s Hope had probably desensitised him to the risks of transiting close to the shore.
Despite the inadequate passage plan having been in place since Alfred entered service in 2019, this significant safety issue went undetected by annual company audits and MCA surveys.
Orkney Islands Council Harbour Authority VTS operators did not raise the alarm when Alfred entered the harbour’s warning area around Swona Island because they were used to the vessel following a variety of inshore routes and viewed the ferry as low risk.
Alfred’s master had held a PEC since 2004; however, Orkney Islands Council Harbour Authority’s 5-yearly revalidation process did not assess the effectiveness of his passage plan nor review his previous navigational tracks.
- Safety issues not directly contributing to the accident that have been addressed or resulted in recommendations
Once aground, the initial emergency response by Alfred’s master did not follow the procedures outlined on the passenger safety video or the actions listed in the vessel’s SMS, leading to passenger confusion.
The master attempted to manoeuvre the vessel off the rocks immediately after grounding, rather than waiting for the C/O to report the results of the hull inspection. The need to keep the vessel in place until a full damage assessment had been completed was not reflected in the grounding/stranding checklist.
Despite the vessel being aground for over an hour, neither the crew nor the Pentland Ferries ERT sought to obtain a nominal list of people on board, their injuries, or whether they had been evacuated to the lifeboat.
The number and severity of injuries suffered by Alfred’s passengers and crew was almost certainly increased because they were not warned to brace for impact before the vessel grounded at a speed of 13kts.
The impact of the grounding caused part of the galley range, catering equipment, and other heavy items to break free of their mountings, risking injury to those on board.
Almost all the vehicles on board Alfred were probably damaged by the impact of the grounding because they had not been secured in accordance with the vessel’s cargo securing manual.
The data from Alfred’s VDR provided critical evidence that underpinned the investigation into this accident.
